Please click on the links to view and download the PDF files:
2004 Annual SHOT Report Summary (682kB pdf)
2004 Annual SHOT Report (314kB pdf)
Please cite this document as:
Stainsby D (Ed.), Jones H, Boncinelli A, et al, on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group. The 2004 Annual SHOT Report (2005).
SHOT Erratum 2004
Page 24, IBCT chapter, bottom of page
Please note that the last learning point on this page was omitted from the printed version.
This version only should be used.
Learning points
- Correct procedures must be followed for patient sampling
- A decision to transfuse must be based on clinical assessment as well as laboratory results – look at the patient!
- Blood components must not be given without prescription
- Blood should only be prescribed by a doctor who has undergone training in blood transfusion and has been assessed as competent
- Diagnostic laboratories must carry out checks to identify large changes in parameters (‘delta checks’) and should not issue unvalidated reports
- Nurses giving blood must familiar with blood components and the indications for their use
- Transfusion laboratory staff should be empowered to challenge inappropriate requests. This will require agreed protocols and training.
Near Miss Table
Report 2004, page 30
Staff involved in “near miss” incidents (n=1076)
Breakdown of staff which fall into the ‘other’ category in the main report (n=32)
| Staff group | Number of incidents involving each staff group |
|---|---|
| A&E team | 3 |
| Taxi driver/courier | 2 |
| Clinical fellow | 1 |
| Health care assistant | 5 |
| Bed manager | 1 |
| Operating department assistant | 4 |
| Student midwife | 1 |
| Support worker | 6 |
| Surgical assistant | 1 |
| Theatre team | 6 |
| Ward auxillary | 2 |
Near miss table – report 2004, page 30